Personality and Mortality
The influence of an individual’s though processes, feelings, and behaviors on health, particularly as these factors pertain to risk of dying. This includes death by any cause, as well as death in the context of diseases.
Personality can be described as characteristic thought processes, feelings, and ultimately, behaviors that exhibit interindividual variation. The link between personality and health has been of interest to the medical and scientific communities for quite some time. Since Friedman and Roseman published their landmark study investigating personality and cardiovascular disease in 1959 (Friedman and Rosenman 1959), there has been a proliferation of research aiming to better define personality and its link with various health outcomes. Initially, there was a focus on defining general classes of personalities that could categorize large groups of individuals into generalizable and stereotypical personality “types.” Many studies have reported associations between these general personality types and all-cause mortality, as well as mortality in the context of specific disease. While such umbrella personality types have evolved over time, an important limitation of their utility in clinical research is their relative oversimplification of complex and multifactorial personalities that individuals exhibit. To this end, efforts to distill discrete and dominant traits that characterize an individual have been instrumental in advancing research on the effects of personality on health. Among the numerous personality traits that have been defined, the “Big Five” personality traits have been most widely utilized in clinical research evaluating mortality risk.
Inherent in the definition of personality is the connection between personality characteristics and behavior. This link provides the basis for investigating the association between personality and mortality. For example, certain personality characteristics may be associated with risky behaviors, which may, in turn, be associated with disease risk and even mortality. Alternatively, specific personality traits and thought processes may place individuals with certain health conditions at a higher risk of developing anxiety and depression. This could also result in worse prognoses and increased mortality risk. The discussion below will review the current state of research investigating the effects of both general personality types and individual personality traits on mortality risk. Methodological strengths, limitations, as well as reasons for inconsistencies between studies will be highlighted.
Personality Types and Mortality
Type A/B Personalities
Personality measures aim to capture fundamental dominant attributes that define a person based on their behavior and interactions with their environment. These measures are designed to describe a personality with a set of key characteristics or a combination of characteristics that are distinctly unique from one another. One such method that has gained broad attention in research and the popular media is to categorize one’s personality as being either A, B, C, or more recently, D. This simple way of typing one’s personality was first coined in the 1950s by two cardiologists, Meyer Friedman and Ray Rosenman, who hypothesized an interaction between personality and cardiovascular outcomes. This hypothesis stemmed from their clinical observations of patients’ general mood, affect, and behavioral patterns in relations to their cardiovascular fitness and prognosis. They divided their patients into three distinct “types” (A, B, and C) based on a personality interview. Type A patients were described as ambitious and competitive individuals; Type B patients were described as laid back and procrastinators; and Type C patients were described as being in a chronic state of insecurity and anxiety (Friedman and Rosenman 1959). Although a person’s personality is much more complex and multidimensional than its “type,” a significant effect of personality type on mortality was still observed. Interestingly, Type A patients were shown to have worse cardiovascular clinical outcomes when compared to Type B or C patients (Friedman and Rosenman 1959). This work pioneered other research initiatives on personality and mortality.
To date, various scales have been developed to compartmentalize people into different personality types. A growing interest in subtyping Type A personality emerged given aforementioned findings of its effect on cardiovascular health. For instance, using the Bortner Scale – a measure of specific Type A personality subtypes – competitiveness in women was shown to be associated with increased risk of all-cause mortality, cardiovascular disease mortality, and ischemic heart disease mortality (Lohse et al. 2017). Further, using the Hunter Type A/B Personality assessment tool (Hunter et al. 1982), Type A personality was nonlinearly associated with cardiovascular risk – measured using body mass index (BMI), fasting blood glucose, and Framingham score (Pollock et al. 2017). This effect is significant to note as personality was shown to impact health outcomes in adolescence and early adulthood (Pollock et al. 2017), lending support for the potential use of personality measures as prognostic indicators of health.
Type D Personalities
Personality typing proved to be an effective way of stratifying individuals in a research setting by showing reliable interactions between specific personality types and health outcomes, as well as mortality. The personality types A, B, and C were then expanded upon to include an additional personality type – D. Type C personality was redefined to include detail-oriented individuals who lack assertiveness, while Type D personalities were characterized by individuals who are distressed and pessimistic. Not surprisingly, Type D personalities gained a lot of attention in clinical work as they were hypothesized to be linked with poor clinical outcomes. This hypothesis is pervasive given empirical evidence showing support for personality Type D as a predictor of long-term mortality in patients with established coronary heart disease (e.g., Denollet et al. 1996). This line of research was not limited to only cardiovascular diseases. Indeed, a large cohort from the Dutch population-based Eindhoven Cancer Registry (n = 2,543) examined the impact of Type D personality on all-cause mortality in patients with colorectal cancers while adjusting for demographics, clinical characteristics, and cardiovascular disease (Schoormans et al. 2017). Remarkably, personality type in females was not associated with mortality, but in males over the age of 70, Type D personality, as well as its negative affect subtype, was significantly associated with an increased risk of all-cause mortality (Schoormans et al. 2017).
Not all research converges on the idea that personality types offer a prognostic factor for all-cause mortality. For instance, no prognostic value of Type D personality was found for all-cause mortality in patients with heart failure (Coyne et al. 2011; Pelle et al. 2009). Instead, anhedonia (Pelle et al. 2009) and a depressed mood (Schiffer et al. 2005) were shown to explain the association between personality types and mortality. Given the aforementioned inconsistencies, more rigorous and systematic approaches are required to attribute personality as a prognostic factor in predicting the natural history of disease.
A systemic review and meta-analysis which included 5,431 observations examined the relationship between personality and all-cause mortality, cardiac mortality, nonfatal myocardial infarction, and cardiac death (Grande et al. 2012). Interestingly, a significant association between Type D personalities and mortality was found; however, the authors note a skew in the data as earlier studies included in the analysis likely overestimated the prognostic value of personality type on mortality due to lack of methodological rigor (Grande et al. 2012). Inconsistencies between studies may be at least partially explained by multiple extraneous factors. First, given the plethora of personality measures, a systematic, valid, and reliable method of measuring personality must be established. This is necessary before any efforts that aim to establish prognostic validity of personality typing are undertaken. Second, any potential biopsychosocial confounding variables that may be contributing to mortality risk must be stringently measured and controlled for in a research setting (e.g., BMI, substance use, socioeconomic status, and cultural background). Finally, personality types are more or less umbrella traits that simplify much more complex and multidimensional characteristics of individuals. Therefore, it would be of interest to disentangle the effects of specific personality characteristics (e.g., social inhibition, pessimism, or aggression) on health outcomes, and to assess their clinical utility as prognostic factors of mortality, instead of group individuals into broad categories based on predefined criteria.
The Big Five
The heterogeneity of personalities within a population and the plethora of adjectives in the English language make it difficult to conduct empirical research. This necessitated the development of a simple, valid, and reliable method of characterizing personality. This marked the transition from characterizing personalities as “types” to characterizing personalities using “traits.” The former method assumes that personalities can be classified into different types that include specific stereotypical attributes, while the latter method uses a combination of different traits to describe personality. The “Big Five” are the most commonly used personality traits in the literature. They represent five preset traits that can be used in combination to describe a personality. The Big Five personality traits include: openness, conscientiousness, extraversion, agreeableness, and neuroticism. These five traits were identified using factor analysis applied to large data sets to objectively identify common descriptors that account for most of the variance within a population (e.g., Barrick and Mount 1991). Since their identification, use of the Big Five personality traits became ubiquitous in research examining the effect of personalities on various outcomes of interest. The following section will define each Big Five personality trait and discuss current findings in relations to their association with mortality.
Openness is defined by having the predilection to novelty, creativity, exploration, and curiosity. Few studies show an association between openness and mortality; however, openness, as well as extraversion and conscientiousness (see below) were shown to correlate with longevity in a Japanese Study that consisted of 1,882 seniors over the age of 60 years, with 70 participants being over the age of 100 years (Masui et al. 2006). Evidence from other studies converges on the idea that openness is a protective factor against mortality (Barrick and Mount 1991; Iwasa et al. 2008; Taylor et al. 2009). However, additional studies investigating the protective effects of openness on mortality have yielded inconsistent results (e.g., Christensen et al. 2002; Jokela et al. 2013b; Turiano et al. 2015; Wilson et al. 2004). A meta-analysis revealed that openness was linked to greater longevity, but only in older individuals, while in younger individuals, openness was not found to be a protective factor (Graham et al. 2017). Indeed, openness in younger individuals was found to be correlated with riskier behavior, such as smoking, suggesting that the effects of openness on mortality may be modified by age (Graham et al. 2017).
Although the relationship between openness and mortality is not straightforward, a discussion regarding the modifying effect of age is still warranted. High openness at a young age may indicate an increased propensity to experience novelty, resulting in riskier behavior such as substance use or smoking. It is likely that such behavior may result in negative health ramifications later in life. On the other hand, openness in older adults may reflect a higher level of intellectual curiosity and flexibility to new experiences, thus making this trait adaptive later in life (Masui et al. 2006). This effect of age may, in part, provide support for the fluidity of one’s personality based on environmental pressures, lending an explanation to how personalities may evolve across a lifetime. In theory, risky health behavior at a young age would be expected to negate the potential positive effects of openness on longevity later in life. In this case, a random sample from the population with an equal distribution of age may show no overall effects of openness on mortality, even when there may be distinct effects in certain age groups. Accordingly, openness may indeed be partially associated with mortality at any given age; however, the evidence to-date does not strongly support this hypothesis.
Conscientiousness defines someone who is organized, self-disciplined, and a careful planner. Someone with low conscientiousness exhibits risky behavior tied to poor health outcomes (e.g., smoking and substance use), while those with high conscientiousness demonstrate exemplary health behaviors, such as avoidance of smoking, regular exercise (Marks and Lutgendorf 1999), and medication adherence (Simpson et al. 2006). Therefore, the inverse association between consciousness and mortality can be logically deduced. Indeed, evidence in the literature support this hypothesis by showing that low consciousness is positively associated with all-cause mortality (Fry and Debats 2009; Graham et al. 2017; Martin et al. 2007; Turiano et al. 2015; Wilson et al. 2004) as well as mortality from specific diseases, such as coronary heart disease (Jokela et al. 2013b), stroke (Jokela et al. 2013b), and chronic renal insufficiency (Christensen et al. 2002). In fact, a meta-analysis involving 3,947 deaths in 76,150 adults from seven cohorts around the world showed that conscientiousness is the most robust personality trait at predicting mortality (Jokela et al. 2013a).
Extraversion is defined as being outgoing and sociable with the tendency to feel stimulated in public settings. It can be argued that an extraverted personality equips a person with the ability to create and maintain strong social networks that offer support in times of need, thereby leading to better health outcomes. Interestingly, some evidence indicates that high extraversion is associated with a lower mortality risk in old age (Fry and Debats 2009; Iwasa et al. 2008; Wilson et al. 2005); however, this effect has not been consistently reported (Jokela et al. 2013a; Turiano et al. 2015; Wilson et al. 2004).
The inconsistencies between studies assessing extraversion and mortality can arguably be explained by extraneous biopsychosocial factors that may have not been consistently accounted for. For instance, individuals with high extraversion traits have a greater likelihood of being smokers or heavy drinkers (Graham et al. 2017; Martin et al. 2007). Interestingly, extraversion has been associated with higher risk of stroke mortality (Turiano et al. 2015). Furthermore, cultural values may be key mediators in the relationship between personality and mortality, and therefore require further exploration (Triandis and Suh 2002). For example, extraversion, conscientiousness, and openness have been shown to be key characteristics in improving resilience (Weiss and Costa 2005); however, this may be true only in cultures that place a high premium on extraversion (Triandis and Suh 2002). Given the impact of social structures on wellbeing, the effect of extraversion on mortality may be overestimated when confounding social factors are not controlled for (Graham et al. 2017).
Agreeableness is defined as the tendency to be cooperative, trusting, and compassionate. Current evidence shows no relationship between agreeableness and mortality (Christensen et al. 2002; Iwasa et al. 2008; Jokela et al. 2013ab; Martin et al. 2007; Turiano et al. 2015; Wilson et al. 2004). These findings may come as a surprise given that agreeableness has been previously linked with improved resiliency (Weiss and Costa 2005), which, theoretically, may translate to increased longevity. However, it can also be argued that increased agreeableness may lead to increased risky behavior as individuals may be more willing to engage in social activities that hinder their overall health (e.g., smoking, binge drinking, and substance use). These negative effects may negate the positive social effects that agreeableness might have on mortality. Further research into the effects of agreeableness on resiliency, risky behavior, and overall mortality are necessary.
Neuroticism is defined as the tendency to be reactive to environmental stimuli and experience negative emotions such as anger, anxiety, and sadness. This trait has been long regarded as a potential public health concern that should be considered in primary care due to its intuitive association with mortality risk (Chapman et al. 2011); however, the findings are more ambiguous than expected. Some studies show evidence in support of the relationship between high neuroticism and increased mortality risk (Christensen et al. 2002; Nabi et al. 2008; Wilson et al. 2004, 2005), with one study finding that neuroticism and perfectionism may both contribute to high mortality risk (Fry and Debats 2009). However, this effect is not robustly found in other research studies (Iwasa et al. 2008; Jokela et al. 2013a; Turiano et al. 2015).
Inconsistencies between these studies may be partially explained by extraneous factors that likely interact with the effect of neuroticism on mortality. For instance, smoking has been shown to explain the relationship between neuroticism and mortality in one study (Graham et al. 2017). This provides a potential explanation to the identified link between neuroticism and increased risk of mortality from coronary heart disease (Jokela et al. 2013b). Further, gender differences were found to explain the effect of neuroticism on mortality, as neurotic males were shown to have a significantly higher risk of mortality when compared to their non-neurotic counterpart, while neurotic females were no different than non-neurotic females (Martin et al. 2007; Mroczek and Spiro 2007). This finding is convergent with similar findings of gender-based difference in the effects of Type D personality and mortality discussed above (Schoormans et al. 2017).
Interesting arguments regarding the potential dichotomy of neuroticism as having both positive and negative effects on longevity have been raised. Specifically, a clear distinction can be drawn between a neurotic individual who exhibits negative affect, anxiety, and depression, versus another neurotic individual, labeled a “worried well,” who actively seeks a physician’s advice for any health concern (Chapman et al. 2011). The former neurotic individual would be expected to have a higher risk of mortality than the latter. This contrast provides interesting insights regarding the complexity of human behavior and the various biological, social, and psychological factors that are in constant interplay with one another.
There is a growing body of evidence linking aspects of an individual’s personality with health outcomes. Indeed, certain personality types and characteristic personality traits may have an influence on longevity, all-cause motility, and prognosis in the context of certain diseases. However, it must be noted that, in reality, the relationships between personality and mortality reviewed here are likely highly complex. It is vital to consider the context in which these associations are examined, including relevant biopsychosocial factors, such as physical activity, socioeconomic status, BMI, and cultural values. Such variables may interact with personality, mortality risk, and each other in complex ways to influence observed associations, or lack thereof, between personality and mortality. Effect modification by age is one notable example which demonstrates the complex interplay between personality and demographic factors. It is likely that other variables may also modify this association between personality and mortality in similar ways. Furthermore, it is important to note that all evidence linking personality with mortality discussed here comes from observational studies. Indeed, the inability to randomly assign personality types to individuals precludes the conduction of randomized controlled trials. Therefore, well-designed observational studies and meta-analysis of such studies will continue to be crucial in elucidating associations between personality and mortality. However, the possibility of residual confounding must be acknowledged, and inferences of causality from such studies need to be interpreted with caution.
Ultimately, a thorough understanding of the connection between personality, behavior, and mortality has the potential to facilitate the identification of “high risk” personality characteristics. Identification of such characteristics may have prognostic value in the context of certain diseases including cancer and cardiovascular disease. More importantly, reliable identification of such traits could lead to the development of targeted psychotherapeutic interventions with the aim of curbing mortality risk.
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